Healthcare Accreditation Certification Program Newsletter
August 2020


Utilization Review - Part One

By: Richard Curtis
Welcome to the first in a four-part series on CMS' expectations for utilization review (UR) in an acute care hospital. In this blog, we'll discuss the basic structure and requirements for a utilization review program. The Condition of Participation (COP) for Utilization Review at ยง482.30 form the basis for discussion.
It's interesting to note that CMS State Survey Agencies have jurisdiction over the COP for utilization review. While accrediting organizations (CIHQ, TJC, DNV, and HFAP) do not review the appropriateness of utilization activities, they do review - to varying degrees - whether a hospital has the structure and processes in place to perform the UR function. The first question to consider is whether or not your hospital even requires a UR plan. There are two exceptions noted by CMS:
  1. Your hospital has an agreement with a Quality Improvement Organization (QIO) which has assumed binding review for your hospital or;
  2. CMS has determined that UR procedures established by your State under Medicaid are superior to the UR requirements for the Medicare program and has required hospitals in your State to meet the UR requirements for the Medicaid program
If your hospital does not meet either exception, then you must have a UR plan and structure in place. A hospital UR plan must address three key domains that address the medical necessity of the following:
  1. Appropriateness of admission – including whether patients are being admitted to the appropriate care setting.
  2. Extended stays in the hospital, and
  3. The use of professional services.
Each of these areas will be discussed in detail in future blogs, so stay tuned. The key structural piece to the UR function is your hospital's UR Committee. CMS is highly prescriptive as to the committee's composition. Your hospital's UR committee must consist of of two or more practitioners. At least two members must be doctors of medicine or osteopathy. The UR committee can be organized as any one of the following:
  • A committee of the hospital
  • A committee of the medical staff;
  • A group outside the hospital that has been established by the local medical society and some or all of the hospitals in the locality, or established in a manner approved by CMS.
Regardless of how your committee is organized, be careful to assure that any individual who engages in the review function is free of potential conflicts of interest. Reviews should not be conducted by any individual who;
  1. Has a direct financial interest (for example, an ownership interest) in that hospital; or
  2. Was professionally involved in the care of the patient whose case is being reviewed.
It's a good idea to have each member of the UR committee sign a conflict of interest statement at the time of initial appointment noting his or her understanding of this requirement and responsibility to recuse himself or herself from a review if necessary.
Join me in a couple of weeks for the second part of this blog series as we examine - in detail - the three domains of utilization review.
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